A presentation for ESRD in pregnancy.

1. ESRD AND PREGNANCY
INTENSIVE HD AND PD
Nikhil Shah
Home Dialysis Therapies Fellow
University of Alberta

2. CKD AND ESRD + PREGNANCY
• Pregnancy in CKD and especially in ESRD is considered high risk
• Several studies have shown that CKD leads to adverse fetal and sometimes
maternal outcomes
• However with advances in the dialysis techniques and as we know more how to
dialyze these precious patients outcomes are improving
• 1980 the successful outcome rate was only 23% 1, in 1998 this increased to 50%2 and
during the last decade reached the 81.3%. 3
1 Successful pregnancies in women treated by dialysis and kidney transplantation: Report from the registration committee of the European Dialysis and Transplant
Association. Br J Obstet Gynaecol. 1980; 87 :839–845.
2 Bagon JA, Varnaeve H, DeMuylder X, Lafontaine JJ, Marten J, Van Roost G. Pregnancy and dialysis. Am J Kidney Dis . 1998; 31 :756–765.
3 Piccoli GB, Conijin A, Consiglio V, et al. Pregnancy in dialysis patients: Is the evidence strong enough to lead us to change our counseling policy? Clin J Am Soc
Nephrol 2010; 5 :62–71.

3. REASONS FOR SEXUAL DYSFUNCTION AND
INFERTILITY
• Sexual dysfunction
• anemia,
• polypharmacy,
• depression,
• loss of sexual desire,
• difficulties in marital life result in reduced
conception.
• Infertility
• Hormonal Imbalance
• hormone (FSH) levels are comparable to or slightly
lower than those in nonuremic controls,
• luteinizing hormone (LH) levels are elevated
• fail to have the luteal surge in LH
• Both progesterone and estradiol levels are extremely
low
• prolactin levels are higher
• subclinical hypothyroidism
• altered levels of HCG
• reduced renal leptin clearance,
• Anovulatory cycles
Mantouvalos H, Metallinos C, Makrygiannakis A, Gouskos A: Sex hormones in women on hemodialysis. Int J Gynaecol Obstet 22:367–370, 1984
Lim VS, Henriquez C, Sievertsen G, Frohman LA: Ovarian function in chronic renal failure: evidence suggesting hypothalamic anovulation. Ann Intern Med 93:21–27, 1980
Gomez F, de la Cueva R, Wauters JP, Lemarchand-Beraud T: Endocrine abnormalities in patients undergoing long-term hemodialysis. The role of prolactin. AmJMed 68:522–530, 1980
Hou SH, Grossman S, Molitch ME: Hyperprolactinemia in patients with renal insufficiency and chronic renal failure requiring hemodialysis or chronic ambulatory peritoneal dialysis. Am J Kidney Dis
6:245–249, 1985

4. WHAT IS THE INCIDENCE ON HD AND PD
• European Dialysis Transplant Association –
1970s
• That registry collected data from 67 centers in 16
countries (approximately 13,000 women), and
reported pregnancy to be an exceedingly rare
event (<1%).
• Belgium -1996
• 32 dialysis centers, representing 1472/4135
patients of were women of childbearing age
• incidence rate of pregnancy progressing beyond
the first trimester to be 0.3 per 100 patient-years
(15 cases)
• Japanese national registry
• 172 pregnancies occurring in 38,889 women on
dialysis, a calculated conception rate of only 3.4%.
• Saudi Arabia
• HD – 5-7.5%
• PD – 0%
• US
• slightly higher rate of 2.4% of hemodialysis
patients became pregnant over a 4-year period
(1992–1995) compared to 1.5% previous incidence.
• For PD 1.1%
• Canada – Toronto
• seven pregnancies in 45 women of childbearing age
on nocturnal hemodialysis for a pregnancy rate of
15.9%

5. COMMON COMPLICATIONS
• 80% of perinatal morbidity and mortality due to prematurity
• 57% intrauterine growth retardation
• 71% polyhydramnios
• 14 – 80% respiratory distress syndrome
• Low Birth weight (1511+/- 284 g)
• NICU stay 7-95 days
• 5.8% of pregnancies are spontaneously miscarried,
• 71% of them end in preterm labor (mean gestational age 32.9 6.7 weeks)
• 37% of them undergo caesarian section
• 30.2% maternal hypertension
• Infant malformations and Maternal Mortality are similar to general
populations
Yang LY, Thia EWH, Tan LK. Obstetric outcomes in women with end-stage renal disease on chronic dialysis: A review. Obstr Med . 2010; 3 :48–53

6. COMPARED TO HD –
PD HAS MORE PROBLEMS
• Peritonitis could conceivably damage
fallopian tubes, but the rate of ectopic
pregnancies reported in this patient
population is not increased.
• Hypertonic solutions in the
intraperitoneal space may interfere with
ovum transport from the ovaries to the
fallopian tubes.
• Abdominal fullness, discomfort, catheter
drainage difficulties, and polyhydramnios
necessitating a progressive decline in fill
volumes
• Bloody dialysate can herald an obstetric
catastrophe including
• placental abruption
• secondary to trauma to the expanding
uterus from the peritoneal dialysis
catheter
• Preterm delivery, premature rupture of
membranes, and stillbirth to occur
secondary to acute peritonitis

7. CANADIAN EXPERIENCE –
TORONTO REGISTRY
• The Toronto Pregnancy and Kidney
Disease (PreKid) Clinic and Registry
• 22 pregnancies in 17 patients
• 18 pregnancies when patient already on
dialysis, 4 started HD during
pregnancy
• Toronto group was significantly older
than the American patients (34 +/- 4yrs
versus 27+/- 6 years; P <0.001)
• American Registry for Pregnancy in
Dialysis Patients (ARPD)
• 70 pregnancies – 57 in patients on
dialysis, 13 started during pregnancy

9. DIALYSIS INTENSITY PROPORTIONAL TO
OUTCOMES

10. DIALYSIS INTENSITY PROPORTIONAL TO
OUTCOMES

11. COMPLICATIONS
Canadian Cohort
• All except 2 patients delivered vaginally
• Short cervix, precipitous delivery and
need for cervical cercelage – 4 patients
• Transient polyhydramnios – 1 patient
• PreEclampsia – 1 patient
• Placental insufficiency – 3 patients
• First trimester loss – 1 patient
American Cohort
• the mean gestational age - 32.7 +/- 3.1
weeks
• mean gestational weight of 1554+/-663 g.
• Preeclampsia (19%),
• polyhydramnios (40%),
• transfusions (25%),
• hypertension (70%)

12. Asamiya Y, Otsubo S, Matsuda Y, Kimata N, Kikuchi K, Miwa N, Uchida K,MineshimaM,MitaniM,Ohta H, Nitta K, Akiba T: The importance of low blood urea nitrogen
levels in pregnant patients undergoing hemodialysis to optimize birth weight and gestational age. Kidney Int 75: 1217–1222, 2009

13. PD DATA
• Redrow at al
• described 14 pregnancies of which 4 ended in spontaneous abortion
• Four were patients approaching ESRD who were started on either peritoneal dialysis (n
= 2) or hemodialysis(n = 2), and therefore had significant residual renal function
• three established peritoneal dialysis patients delivered babies weighing 1065–1720 g
between 32 and 34 weeks of gestation, whereas the hemodialysis patients delivered
babies weighing 2044 and 2218 g at 35 and 36 weeks of gestation, respectively
• Several case reports – small numbers, difficult to interpret results
• Most cases would report a slight benefit of HD

14. HOW DOES PD HELP
• PD offers specific benefits for management of the pregnancy,
• such as more continuous and gentle daily ultrafiltration,
• metabolic balance without the fluctuations noted in intermittent therapies,
• less anemia,
• avoidance of systemic anticoagulation,
• more liberal diet for maintaining maternal nutrition
• But, data is from 1980s and 90s before intensive hemodialytic therapies were widely
adopted.
Redrow M, Cherem L, Elliott J, Mangalat J, Mishler RE, Bennett WM, et al. Dialysis in the management of pregnant
patients with renal insufficiency. Medicine (Baltimore) 1988; 67:199–208.
Jakobi P, Ohel G, Szylman P, Levit A, Lewin M, Paldi E. Continuous ambulatory peritoneal dialysis as the primary
approach in the management of severe renal insufficiency in pregnancy. Obstet Gynecol 1992; 79:808–10.

16. PD PRESCRIPTION
• Most common –
• Less volume ~ 1.5L
• More exchanges – 4-6 /day
• APD
• 1.5 – 2L exchanges x 4
• Plus 1-2 day exchanges
• No report of Icodextrin!
• Residual renal function important
Batarse RR, Steiger RM, Guest S. Peritoneal Dialysis
Prescription During the Third Trimester of Pregnancy. Perit
Dial Int. 2015 Mar 1;35(2):128–34.

17. WHY DOES INTENSE DIALYSIS HELP
• clinical (BP, left ventricular hypertrophy),
• biochemical (urea and phosphate clearance,
anemia),
• biologic parameters (endothelial function,
inflammation),
• clearance of urea and likely other solutes.
• negative relationship was noted between
• BUN and birth weight (r=20.53, P=0.02)
• BUN and gestational age (r=20.50, P=0.02).
• Birth weight of at least 1500 g was achieved at a
BUN of 49 mg/dl (urea 17.9 mmol/L)
• Gestational age of at least 32 weeks was achieved
at a BUN of 48 mg/dl (urea 17.1 mmol/L).
• Residual renal function
• improve pregnancy outcomes
• live birth rates favored women who conceived
before the initiation of dialysis compared with
established dialysis patients
• Women with more residual kidney function
requiring less intensive dialysis
Asamiya Y, Otsubo S, Matsuda Y, Kimata N, Kikuchi K, Miwa N, Uchida K,MineshimaM,MitaniM,Ohta H, Nitta K, Akiba T: The importance of low blood urea nitrogen
levels in pregnant patients undergoing hemodialysis to optimize birth weight and gestational age. Kidney Int 75: 1217–1222, 2009

18. MANAGEMENT
Vázquez JAG, Calva IEM, Fernández RM, León VE, Cardona M, Noyola H. Pregnancy in End-Stage Renal Disease Patients and Treatment with Peritoneal
Dialysis: Report of Two Cases. Perit Dial Int. 2007 May 1;27(3):353–8.

19. MANAGEMENT
• Medication review
• Stop RAS inhibitors
• Stop Statins
• Review Immunosuppression if any
• Diet
• Double dose of Multi Vitamins
• Folic acid 5 mg PO daily
• “Unrestricted diet”
• Protein 1.5 – 1.8 g/kg/d
• Dialyzate bath
• Potassium 3.0
• Bicarb 25
• Calcium 1.75
• Sodium Phosphate – add to bath
• Anemia
• Increase EPO to weekly / double the dose
• IV and oral iron
• Target Hb 110

20. MANAGEMENT
• DW –
• During the first trimester, expected weight gain is minimal – 0.5
kg/ month.
• while during the second and third trimesters, the dry weight can
be expected to increase by up to 0.5 kg⁄ week.
• Calcium and Phosphorus
• Within normal limits for your lab
• PTH
• Within KDOQI guidelines for non pregnant patients
• Targets
• Urea - ~10 mmol/L
• Hemoglobin – 10 -11 g/l
• BP - <130 /80
• Use MethylDopa, Labetolol, Nifedepine, Hydralazine
Barua M, Hladunewich M, Keunen J, Pierratos A, McFarlane P, Sood M, et al. Successful Pregnancies on Nocturnal Home
Hemodialysis. CJASN. 2008 Mar 1;3(2):392–6.

21. Barua M, Hladunewich M, Keunen J, Pierratos A, McFarlane P, Sood M, et al. Successful Pregnancies on Nocturnal Home
Hemodialysis. CJASN. 2008 Mar 1;3(2):392–6.

22. Barua M, Hladunewich M, Keunen J, Pierratos A, McFarlane P, Sood M, et al. Successful Pregnancies on Nocturnal Home
Hemodialysis. CJASN. 2008 Mar 1;3(2):392–6.

23. DIAGNOSIS OF PREECLAMPSIA IN ESRD
• diagnosis of preeclampsia relies on the
assessment of
• worsening blood pressure
• alterations in placental Doppler blood
flow,
• Fetal growth restriction,
• hematological alterations - suggestive
of the HELLP Syndrome (elevated liver
transaminases and decreased
platelets).
• Newer tests?
• sFLT1

24. MAIN FACTORS FOR SUCCESS
• Intensive dialysis
• Erythropoietin
• Calcium and phosphorus management
• BP management
• Maternal nutrition
• Iron and Folate supplementation
• Monitoring - Maternal
• Monitoring – Fetal
• Compliance

25. ROLE OF THE FETAL MEDICINE AND
OBSTETRIC SPECIALISTS
• Fetal Monitoring
• First trimester screen (nuchal translucency, PAPP-A, bhCG)
between 9 and13 weeks)
• Maternal serum screen (AFP, total hCG, inhibin A and
unconjugated estriol) between 15 and 18 weeks
• Level II US tomeasure cervical length and assess for anomalies
at 18–20 weeks
• Placental US with Doppler assessment at 22 weeks
• Weekly US and BPP from 26 weeks until delivery
• Obstetric monitoring
• Cervical insufficiency
• Steroids to promote lung maturity
• Premature labour
• Progesterone administration?
• Bleeding
• Cesarean section
• Lactation +/- suppression
• Neonatal Monitioring
• Apgar scores
• NICU?
• IUGR/SGA/Premie
• Growth charting/ Milestones
• Defects – cognitive or physical?

26. THANK YOU